Drug prices are on the March
As a non-profit, we at 46brooklyn have made it our goal to provide insights into U.S. drug pricing data available in the public domain based upon the figures we’ve gathered over the prior month. This month is of course no different – reviewing the latest drug pricing changes from March 2025.
If you’ve followed our work, you already know that drug pricing can be a tricky subject to fully understand, especially because of all the players involved (think PBMs, pharmaceutical manufacturers, wholesalers, pharmacies, insurers, etc.), the opacity and inconsistency that can occur within each player’s dealings with one another, and the lack of discernible detail that constitutes net drug pricing realities.
However, of all of these players in the drug channel, perhaps no player is more critical in determining drug pricing reality than pharmacy benefit managers (PBMs) – as they are the intermediaries between insurers, drug manufacturers, and pharmacies – who work, as they say, as the only player in the prescription drug supply chain to reduce the costs of medicines. Simply put, the more that the architecture of the drug channel fails to incentivize low sticker prices for medicines, the greater reliance our system has on negotiators like PBMs to determine the actual costs that are going to be incurred for those transactions.
As concerns over rising prescription costs fester and grow in the U.S., in some ways, this intrinsic system dependence on PBMs can result in a disproportionate focus on how they operate versus other members of the drug channel. No doubt, that can mean that players like wholesalers, for example, will enjoy less scrutiny than PBMs in not just our work and research, but also in the halls of Congress and in state capitols across the country. While this lack of focus-balance will understandably draw ire from PBMs and their proponents – whether fair or not – in a world of bloated prices, the incentives and actions of PBMs arguably become what matters most to purchasers of pharmaceuticals (if for no other reason than their connected position to those purchasers [health plans and patients]).
As a result, drug pricing reform and PBM reform often can be somewhat synonymous with one another; meaning PBM reform is often undertaken as a mechanism to achieve prescription drug spending reform.
But as the past few weeks have shown, the push for PBM reform isn’t just about drug costs – it can also be about other aspects of how PBMs impact the pharmacy marketplace and how patients access their prescriptions and pharmacist services.
As many of you know, PBMs aren’t just PBMs anymore. In their recently updated drug channel vertical integration mapper, the Drug Channels Institute highlights how integrated PBMs have become infused within larger and broader healthcare conglomerates that feature affiliated insurers, group purchasing organizations (GPO), wholesalers, pharmacies, prescribers, and even manufacturers. With this market evolution, PBMs no longer just interact with other components of the prescription drug supply chain — they often own them. As a result, there is little to no external pushback from independent entities within these segments, removing competitive pressure that might otherwise influence pricing behaviors.
Within this context, five out of the six largest PBMs have associated parent companies that manage insurance firms or healthcare clinics, and the six largest PBMs have their own affiliated pharmacies. This means that while PBMs are entrusted to establish pharmacy networks that direct prescription traffic from one pharmacy to another and establish the reimbursement rates for the pharmacies in those networks, those same PBMs also have affiliated companies who have a direct competing interest in how those decisions are made and how they impact themselves and their unaffiliated competitors.
Figure 1
Source: State of Ohio Board of Pharmacy
So follow the incentives of these publicly-traded companies, and the expected outcomes often emerge.
On the pharmacy network side, while pharmacy openings and closures data is known to be fraught with limitations and confounding variables like 340B spread access, our home state of Ohio recently released some rather compelling data showing an overall attrition of outpatient pharmacies across the state since 2015, with a net loss of 16%, or 350 locations, through 2024 (Figure 1). For those interested, Marty Schladen over at the Ohio Capital Journal did a great job chronicling the lead-up to the 2016 inflection point where Ohio’s pharmacy closures officially started outpacing the openings.
On the reimbursement side, while we certainly have documented many of the inequities and disparities that can occur from drug-to-drug and pharmacy-to-pharmacy over the years, we think the FTC’s second interim report is a good showcase of what can happen when PBMs control the dials of reimbursement for both affiliated and unaffiliated pharmacies (spoiler alert: the Force is strong with PBM prices).
But regardless of the why and how, community pharmacy headwinds are just plain fact at this point, and the growing public health threat of pharmacy deserts is real. And these challenges are not just unique to small, independent pharmacies. Rite Aid is still flailing after slowly selling off its once-sizable pharmacy portfolio. Even a big pharmacy like Walgreens has not been able to keep up with the demands of its business and PBM reimbursement and will close 1,200 locations over the next three years – creating an even bigger pharmacy deficit than the current state of affairs.
We bring this up on the front-end of this report, because, while we are only a few months into the new year, several states are hunkering down and digging their heels in to really push for some big changes in the pharmacy world. As the feds continue their slow and never-ending plod on some kind of PBM reform, many states aren’t waiting around and are taking matters into their own hands. For example, Alabama Governor Kay Ivey signed a PBM reform bill into law in April. This law ties commercial reimbursement for independent pharmacies to the state’s Medicaid reimbursement methodology, which uses a state-based average acquisition cost benchmark plus a professional dispensing fee of $10.64.
Additionally, in a somewhat surprising turn of events, Arkansas Governor Sarah Huckabee-Sanders signed a law that prohibits PBMs from also owning pharmacies. This law, modelled somewhat like the legislation introduced in the last Congress by Senators Josh Hawley and Elizabeth Warren and Representatives Diana Harshbarger and Jake Auchincloss, gathered momentum quickly upon its introduction, resulting in overwhelming support from lawmakers before being sent to Huckabee-Sanders, who has been touting Arkansas’ first-in-the-nation status on the policy. Of course, kicking out PBM-owned pharmacies from the state has led to some speculation that this action may benefit the Walmart-sized pharmacies of Arkansas more than the small, independent operators.
On a related front, just a few days before the Arkansas law being signed, the National Association of Attorneys General sent a powerful letter urging congressional leaders to pass a federal act prohibiting PBMs from owning or operating pharmacies.
While there are certainly many newsworthy items from the past few weeks, these developments stick out the most. Whether you agree with some of these PBM reforms or not, the big takeaway for us is that as the feds continue their PBM reform push in what increasingly seems like a bridge-to-nowhere, given the consistent lack of results, for better or worse, states continue to be the place to watch for material policy reform attempts.
The Cliff Notes from last month’s drug price changes
There were a net nine brand drug list price increases in March. Price changes ranged from a 16% WAC price decrease to a 9.9% WAC price increase. However, depending on the price of a medication, even a small overall percentage increase could be substantial enough to be thousands or even millions of dollars compounded over time.
Some of the biggest and/or most interesting movers to take note of for March 2025 were:
Iluyma solution for injection (4.2% increase; $24 million in gross prior year Medicaid expenditures [PYME])
Winlevi topical cream (2.3% increase; $17 million PYME)
Cinqair solution for injection (2% increase; $179k PYME)
Keytruda solution for injection (2% increase; $579 million PYME)
Ultiva solution for injection (9.9% increase; $3k PYME)
Gamifant solution for injection (-10.2% decrease; $3 million PYME).
As we stated above, a 2% increase on a drug associated with $579 million in PYME (i.e., Keytruda) is likely a more significant event than a 9.9% increase on a $3k PYME product (Ultiva); unless of course you’re the person taking that drug and exposed to that cost increase – potentially without the benefit of any off-setting rebates enjoyed by government programs, PBMs, and plans … which reminds us, bear in mind that as you read these numbers, that they are the list prices before drugmaker rebates, which as we know are growing significantly over time and are at their largest amounts in the Medicaid and 340B programs.
On the generic side of the coin, year-over-year (YoY) generic oral solid price deflation is at 12.1% (per National Average Drug Acquisition Cost, or NADAC).
If you’re only looking for the high-level overview, then hopefully the above meets your needs. If you want more of the details, read on.
What we saw from brand-name medications in March
1. A small number of brand drug list price changes, in-line with most months of March
There were a total of 11 brand-name medications that saw wholesale acquisition cost (WAC) price increases in March and two that took decreases (so nine net increases), which is featured and contextualized in our Brand Drug List Price Change Box Score, which pulls WAC pricing data from Elsevier.
Price changes this month ranged from -16% to +9.9%.
As a reminder, brand drug list price increases in Medicaid are largely held in check thanks to the Medicaid Drug Rebate Program (MDRP), which includes rebate penalties for drug price increases that occur faster then the rate of inflation. Medicare now has similar cost containment provisions. Commercial employers and cash-paying patients may lack legislated protections from price increases – especially those that occur faster than the rate of inflation.
This is one of a number of reasons that solely analyzing brand list price changes provides an incomplete picture of what’s really happening with brand manufacturer economics, thanks to the growing lot of opaque rebates, discounts, and giveaways that drugmakers shave off those list prices. But alas, until drugmakers, PBMs, insurers, wholesalers, 340B covered entities, and rebate aggregators make more granular data on net prices public, we’ll continue working with what we’ve got.
2. Brand price trends over time
Figure 2
Source: Elsevier Gold Standard Drug Database, CMS State Drug Utilization Data, 46brooklyn Research
To help contextualize brand-name drug list price increase behavior, we find it beneficial to review past trends. In comparison to the data from prior months of March, this year seems to be decently close with March 2021, which had 11 net (combined increases and decreases) branded price changes. Looking at past trends, March overall, is a month where there have been consistently a smaller number of branded price changes; however, the total this March is lowest we have seen since beginning to track this information in 2012.
The highest number of March brand price changes occurred two years ago in 2022 with 70 net branded price increases; whereas the lowest was this last month, March 2025, when there were only nine net price increases.
To put it into a more recent perspective (over the last five years), in March 2024, there were a net (increases and decreases) of 31 medications, 13 in March 2023, 70 in March 2022, 11 for March 2021, and 17 in March 2020.
Moreover, when further examining our brand drug box score visualization, we continue to see March being the time of year where there is a small amount of change for both brand price increases and brand price decreases.
Of the drugs that took increases so far this year, the median price increase has been 4.0% a percentage that has not fluctuated much since 2019 (Figure 2).
3. Brand drug list price changes worth taking note of in March 2025
We identify drugs worth taking note of in a couple different ways. Primarily, we look for medications with a lot of prior Medicaid expenditures. We next look for drugs with large pricing changes (+/- 10%). And finally, we look for drugs that are interesting for us either because we’ve previously written on them or because we find them of unique clinical value. This month, when looking for these drugs in the brand arena, we have several of each worth mentioning:
Inflammatory conditions (psoriasis, acne, etc.)
ILUYMA solution for injection (tildrakizumab-asmn) is an interleukin-23 antagonist indicated for the treatment of adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy. This medication took an increase in WAC of 4.2%, impacting $24 million in gross prior year Medicaid expenditures (PYME). Recently, ILUYMA’s clinical trial(s) have shown significant efficacy in improving nail psoriasis severity, which is a difficult to treat population and an area where other treatments tend to fall short and lead to a negative impact on quality of life.
Winlevi topical cream (clascoterone) is an androgen receptor inhibitor indicated for the topical treatment of acne vulgaris in patients 12 years of age and older. This medication saw an increase in WAC of 2.3%, impacting $17 million in PYME.
Asthma
CINQAIR solution for injection (reslizumab) is an interleuikin-5 antagonist monoclonal antibody (IgG4 kappa) indicated for add-on maintenance treatment of patients with severe asthma aged 18 years and older, with an eosinophilic phenotype. This medication experienced an increase in WAC of 2.0%, impacting $179k in PYME. CINQAIR is listed as an excluded medication on Express Scripts 2025 National Preferred Formulary (less clear if excluded on Caremark and Optum’s formularies, as it doesn’t appear to be listed one way or another) with the PBM suggesting alternatives such as Dupixent, Fasenra, Nucala, Tezspire, and Xolair.
Cancer
Keytruda solution for injection (pembrolizumab) is programmed death recepter-1 (PD-1)-blocking antibody used to treat 21 different types of cancer. This medication had an increase in WAC of 2.0%, impacting $579 million in PYME (the highest PYME value in March). In February, the FDA granted priority review as perioperative treatment for resectable locally advanced head and neck squamous cell carcinoma. The PDUFA date is June 23, 2025, which is where the FDA will announce its decision on the Biologics License Application (BLA).
Anesthesia
Ultiva solution for injection (remifentanil) is a u-opioid agonist with rapid onset and peak effect, and short duration of action. This medication experienced an increase in WAC by 9.9%, impacting $3k in PYME. As of April 6, 2025, the generic of Ultiva, remifentanil, is listed on shortage due to increased demand, which may explain some of this behavior (to the extent that this drug’s price is responding to potential demand).
Rare disease
Gamifant solution for injection (emapalumab-lzsg) is an interferon gamma (IFNy) blocking antibody indicated for the treatment of adult and pediatric (newborn and older) patients with primary hemophagocytic lymphohistiocytosis (HLH) with refractory, recurrent, or progressive disease or intolerance with conventional HLH therapy. Notably, this medication had a -10.2% decrease in WAC, impacting $3 million in PYME. HLH is a rare condition that can be passed down through genetics and usually affects babies and young children. In addition, it often takes awhile to diagnose due to the symptoms being similar to other diseases including infection or cancer. HLH affects around 1 in 50,000 births worldwide each year, with doctors, scientists, and geneticists continuing to learn more about this life-threatening condition.
In recent news, the manufacturer, Sobi, announced the FDA’s acceptance of their supplemental Biologics License Application (sBLA) for use of Gamifant in adult and pediatric patients with HLH/macrophage activation syndrome (MAS) in Still’s disease with an inadequate response or intolerance to glucocorticoids, or with recurrent MAS. The PDUFA date is June 27, 2025, which is where the FDA will announce its decision on the Biologics License Application.
What we saw from generic medications in March
4. A slightly unfavorable, unweighted price change picture
Each month, we look at how many generic drugs went up and down in the latest month’s survey of retail pharmacy acquisition costs (based on National Average Drug Acquisition Cost, NADAC), and compare that to the prior month (Figure 3).
Basically, the quick way to read Figure 3 is to look for blue bars that are taller than orange bars to the left of the midpoint line, and exactly the opposite to the right of the line. That would indicate a good month – more generic drugs going down in price compared to the prior month, and less drug prices going up.
Figure 3
Source: Data.Medicaid.gov, 46brooklyn Research
Based upon a quick eye check, Figure 3 seems to show a similar amount of drugs both increased and decreased in cost this month when comparing it to the prior month.
When you look at the bar graph on the left side you can see that the blue bars are similar in size as the orange bars, which represents generic price decreases. When taking a closer look, in February for the 0-10% range, there were 4,381 decreases in generic drug prices and slightly more in March with 4,722 decreases. For the 10-20% range, in February, there were 270 decreases in price, whereas in March, there were only 129, which is extremely difficult to visualize from this chart, as the March bar appears non-existent.
To the right of the line, which represents generic drug cost increases, the February and March data are very close to one another with the 0-10% range for February resulting in 17,946 price increases and in March, 19,442 increases. For the 10-20% range, there were 4,239 price increases in February and 2,265 in March.
For every generic drug that decreased in price in March 2025, 4.5 increased in price. But as usual, take this unweighted price change analysis with a grain of salt. To really make heads or tails of all of these pricing changes, let’s weight these changes.
5. Weighted Medicaid generic drug costs come in at $109 million inflation
The purpose of our NADAC Change Packed Bubble Chart (Figure 4) is to apply utilization (drug mix) to each month’s NADAC price changes to better assess the impact. We use Medicaid’s drug mix from CMS to arrive at an estimate of the total dollar impact of the latest NADAC pricing update. This helps quantify what should be the real effect of those price changes from a payer’s perspective (in our case, Medicaid; individual results will vary).
The green bubbles on the right of the Bubble Chart viz (screenshot below in Figure 4) are the generic drugs that experienced a price decline (i.e. got cheaper) in the latest survey, while the yellow/orange/red bubbles on the left are those drugs that experienced a price increase. The size of each bubble represents the dollar impact of the drug on state Medicaid programs, based on utilization of the drugs in the most recent trailing 12-month period (i.e. bigger bubbles represent more spending). Stated differently, we simply multiply the latest survey price changes by aggregate drug utilization in Medicaid over the past full year, add up all the bubbles, and get the total inflation/deflation impact of the survey changes.
Figure 4
Source: Data.Medicaid.gov, 46brooklyn Research
Overall, in March, there was $121.6 million worth of inflationary drugs with an offset of just over $12 million of deflationary generic drugs, netting out to approximately $109.5 million of generic drug cost inflation for Medicaid.
These numbers look similar to what we saw last month in February and previous to that in December but much different than we what saw in January as the month-over-month (MoM) increase and decrease bubbles were around the same size. There has been some speculation that tariffs could increase drug prices; however, as those haven’t gone into effect yet, it is unclear what may be responsible for this two-month trend (to the extent that two points make a line) in rising generic costs in 2025.
6. Year-over-year generic oral solid deflation at 12.1%
Ever since June 2020, we have been tracking year-over-year (YoY) deflation for all generic drugs that have a NADAC price. We once again weight all price changes using Medicaid’s drug utilization data. This month, deflation on oral solid generics and all generics was at 13.4% and 11.2%, respectively (Figure 5). If you are a purchaser of generic drugs, an increase in this metric is ideal, as it means costs are declining. This is right in line with the NADAC Change Packed Bubble Chart, which also showed the cost of generic drugs decreasing. Businesses generally enjoy it when their input costs go down.
Figure 5
Source: Data.Medicaid.gov, 46brooklyn Research
We anticipate the continued flattening of the YoY generic deflation trend, given that NADAC methodology now includes a smoothing component for generic drug prices (inherent to such an effort is a reduction in large swings in inflation/deflation).
7. Top/notable generic drug decreases this month
For March, the drug price decrease and increase bubbles were opposite in size with the decrease bubble being extremely small. After reviewing the various sizes and colors that compromise this month-over-month decrease, there are some notable decreases.
The largest outliers in the packed bubble chart this month include aprepitant 80 mg capsule, which shows the cost decreasing by -17.7%; butalbital-acetaminophen 50-300 tablet by -16.6%; and pyridostigmine ER 180mg tablets by -13.7 %.
Aprepitant has previously been mentioned at 46brooklyn in this article from November 2021, where the price of a different form of the medication (i.e. an injectable versus tablet) had taken a 2.2% price increase, impacting at the time $9 million gross PYME. Aprepitant 80 mg capsules are used for the prevention of chemotherapy-induced nausea and vomiting as well as postoperative nausea and vomiting. The generic capsules are unique, as only they are (compared to the brand name) indicated for postoperative nausea and vomiting.
Butalbital-acetaminophen 50-300 tablet is indicated for tension-type headaches (also known as TTH). This medication took a -16.6% decrease in price. Butalbital-containing analgesics should only be used three or fewer days per month. Using butalbital-acetaminophen should be done with caution, as it can lead to medication overuse headaches. Medication overuse is a common question asked on prior authorization forms by PBMs when it comes to their review of paying for certain migraine medications. Butalbital-acetaminophen has a limited role in TTH, as their use is often reserved for highly selected patients with episodic TTH who are unresponsive to simple analgesics or combination analgesics with caffeine when dose limits have been established, and therapy is being monitored.
Pyridostigmine ER 180 mg tablet is indicated for myasthenia gravis, which is a rare condition that affects muscles, causing them to be weak and tired. This medication took a -13.7% price decrease. This decrease is interesting, as pyridostigmine bromide ER 180 mg tablets are on nationwide backorder from both Alvogen and Rising Pharmaceuticals as of February 23, 2025. Both pharmaceutical companies have not provided a reason for the shortage nor an estimated resupply date. A reminder that if you think you know how the drug pricing winds will move based upon an event, the drug channel is often ready to surprise you.
8. Top/notable generic drug increases
On the increase side of things, notable this month is that none of the generic drug increases were in the dark-to-burnt-orange bubble color of our bubble chart, which means percent changes were on the lower end of the scale. For example, we usually start this section off by noting the most impactful increases of 50% or above; however, no increases were even close this month. However, some notable ones include methylphenidate ER(LA) 40 mg capsules (25.6% increase), lamotrigine ODT 200 mg tablet (25.5% increase), and temozolomide 140 mg capsule (20.6% increase).
Over at least the least year (but likely longer), ADHD medications have been on a worldwide shortage (not just within the United States) and continue to show up each month in BOTH our generic drug price increases and decreases in some capacity. Unfortunately, there is not an end in sight for the shortage, as it continues to compound day in and day out, leaving patients searching for pharmacies that have any ADHD medications in stock, which perpetuates the problem, and many times leaves the patient (or caregiver) feeling frustrated.
Lamotrigine ODT 200 mg tablet is an orally dissolving tablet, meaning that it will dissolve rapidly on the tongue and can be swallowed with or without food or water. This medication is used for seizures as well as bipolar disorder. It increased in price last month by 25.5%. Lamotrigine ODT is a repeat offender in these reports, as we also saw this drug in the data back in October 2024 (albeit the 50 mg version).
Temozolomide 140 mg capsule is indicated for various brain tumors and increased in price last month by 20.6%. Just a few days ago, temozolomide was highlighted in the news when Professor Gilles Vassal, the Head of Pediatric Research at Gustave Roussy, suggested that this medication be added to the WHO’s list of essential medicines for children.
A gallery of the price behavior of these drugs over time is provided below:
That’s all for this month! Come back to 46brooklyn next month to see if Spring has sprung especially as it relates to drug price changes and how it may impact the healthcare continuum.
Big thanks to Rob Volansky at Healio for a well-nuanced piece on the FTC’s second interim PBM report, with some excellent context on government’s role in policy designs that further increase our system’s reliance on PBMs.
Shout-out to Zach Brennan at Endpoints News for capturing some of the drug price change details in his recent look at the January 2025 price increase and decrease numbers.
Check out this great discussion on the ASCP Rxperience Podcast, where 46brooklyn president Ben Link waxes poetic on drug price benchmarks, PBMs, and the state of pharmacy.
More thanks to Ken Alltucker at USA Today for including our thoughts in his piece on the potential fall-out of tariffs on medicines and how any newly imposed taxes could impact the prices of medicines.
Lastly, more credit due to Marty Schladen at the Ohio Capital Journal for his piece mentioned above on the new data from the Ohio Board of Pharmacy tracking pharmacy closures and openings over time.